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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610613
Report Date: 02/13/2025
Date Signed: 02/13/2025 04:11:05 PM

Document Has Been Signed on 02/13/2025 04:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WHITE'S ADULT HOME CAREFACILITY NUMBER:
197610613
ADMINISTRATOR/
DIRECTOR:		WHITE, ANTONIAFACILITY TYPE:
740
ADDRESS:36426 GEIGER AVETELEPHONE:
(661) 993-3116
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 0DATE:
02/13/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Edmond and Antonia WhiteTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 02/13/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced pre-licensing visit to this facility and met with the Licensee. This is a new application and a fire clearance dated 05/10/2024 was received for four (4) ambulatory residents.

The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6. Component III was conducted with the applicant from 9:45 am until 11:00 am.

Today’s site visit consisted of LPA touring the physical plant inside and outside from 11:00 am until 11:30 am. LPA Spaeth observed the following:

Living Room – the living room contained comfortable seating.

Dining Room - The dining room contained a dining room table and chairs.

Kitchen/Family Room - There is a seven-day supply of non-perishable food and a two-day supply of perishable foods. A fire extinguisher is also located near the kitchen. Appliances in the kitchen appeared to be functional. The family room contained comfortable seating and a television.

Medication Closet - The closet was locked and will be the storage area for clients' medications, clients' files and staff files.

Continued - 809C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WHITE'S ADULT HOME CARE
FACILITY NUMBER: 197610613
VISIT DATE: 02/13/2025
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Backyard - The backyard contained a shaded area and comfortable seating. The side gate leading from the back yard to the front yard was not locked.

Water Temperature - The water temperature was tested at 11:00 am and was 117 degrees F.

Bedrooms - There are four bedrooms which contained bed, linens, night stand, chest of drawers, a chair and a closet.

Bathrooms- The bathrooms contained hand soap, paper towels, and trash can.

Laundry Room - The washer, dryer, and clean linens are located in this room.

Garage – the garage was locked and contained the cleaning solutions.

Hallway Closet - the closet contained PPE supplies

The smoke and carbon monoxide detectors were tested at 11:25 am and were operable. The facility was clean and appears to be in good repair.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
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